Upper Airway Obstruction in a Newborn: A Rare Cause of Respiratory Distress.

Newborns are considered obligate nasal breathers until the eighth week of life. Therefore, upper nasal obstruction in a newborn can present as a potentially life-threatening complication. Congenital nasal pyriform aperture stenosis (CNPAS) is a rare form of upper airway obstruction caused by a narrowing without occlusion in the most anterior opening of the bony nasal airways. According to the severity of this stenosis, early onset of respiratory symptoms can arise in the newborn. In this article, we present the case of a male term newborn with no prior relevant family history and uneventful gestation delivered in a eutocic manner with an adequate transition to the extra-uterine environment. On his first day of life, progressive respiratory distress, inability to breastfeed, and impossibility to make nasogastric probe progress through both sides of the nose were observed, leading the newborn to be admitted to a neonatal intensive care unit. During imagiological assessment with perinasal computerized tomography (CT) scan, an almost total occlusion of the pyriform aperture and a solitary median maxillary central incisor (SMMCI) were identified. Additional evaluation with brain magnetic nuclear resonance imaging (MRI) was unremarkable with no midline defects identified. Endocrine laboratory assessment was also normal. The newborn underwent pyriform aperture permeabilization surgery via a sublabial approach with bilateral nasal stent introduction, enabling total resolution of the initial respiratory symptoms. No incurrences were reported during the post-operatory follow-up period. With the present case report, the authors are trying to raise awareness for CNPAS not only as a rare cause of respiratory distress in the newborn but also as a clinical entity that can be associated with midline defects, which require further additional investigation and intervention.

Nephrotoxicity in Neonates.

Acute kidney injury (AKI) is classified based on prerenal, intrinsic, and postrenal causes. In the newborn, AKI can occur after an insult during the prenatal, perinatal, or postnatal period. AKI is usually an underrecognized condition and its true incidence is unknown. AKI may result from the administration of a number of different nephrotoxic medications, which are often used concurrently in critically ill neonates, exponentially increasing the risk of renal injury. Drug toxicity may also compromise the formation and development of nephrons, and this is particularly important in preterm infants, who have incomplete nephrogenesis. Little is known about the pharmacokinetics and pharmacodynamics of different medications used in neonates, especially for the most immature infant, and the use of most medications in this population is off label. Strategies to prevent AKI include the avoidance of hypotension, hypovolemia, fluid imbalances, hypoxia, and sepsis as well as judicious use of nephrotoxic medications. Treatment strategies aim to maintain fluids and electrolytic and acid-base homeostasis, along with an adequate nutritional status. Neonates are especially prone to long-term sequelae of AKI and benefit from long-term follow-up. This review summarizes the most relevant aspects of nephrotoxicity in neonates and describes the prevention, treatment, and follow-up of AKI in neonates.

Respiratory Care for the Ventilated Neonate.

Invasive ventilation is often necessary for the treatment of newborn infants with respiratory insufficiency. The neonatal patient has unique physiological characteristics such as small airway caliber, few collateral airways, compliant chest wall, poor airway stability, and low functional residual capacity. Pathologies affecting the newborn's lung are also different from many others observed later in life. Several different ventilation modes and strategies are available to optimize mechanical ventilation and to prevent ventilator-induced lung injury. Important aspects to be considered in ventilating neonates include the use of correct sized endotracheal tube to minimize airway resistance and work of breathing, positioning of the patient, the nursing care, respiratory kinesiotherapy, sedation and analgesia, and infection prevention, namely, the ventilator-associated pneumonia and nosocomial infection, as well as prevention and treatment of complications such as air leaks and pulmonary hemorrhage. Aspects of ventilation in patients under ECMO (extracorporeal membrane oxygenation) and in palliative care are of increasing interest nowadays. Online pulmonary mechanics and function testing as well as capnography are becoming more commonly used. Echocardiography is now a routine in most neonatal units. Near infrared spectroscopy (NIRS) is an attractive tool potentially helping in preventing intraventricular hemorrhage and periventricular leukomalacia. Lung ultrasound is an emerging tool of diagnosis and can be of added value in helping monitoring the ventilated neonate. The aim of this scientific literature review is to address relevant aspects concerning the respiratory care and monitoring of the invasively ventilated newborn in order to help physicians to optimize the efficacy of care.

Value of Chest Radiographic Pattern in RSV Disease of the Newborn: A Multicenter Retrospective Cohort Study.

Respiratory syncytial virus (RSV) lower respiratory tract infection is the most common viral respiratory infection in infants. Several authors have sought to determine which risk factors are the best predictors for severe RSV disease. Our aim was to evaluate if a specific chest radiographic pattern in RSV disease can predict the disease severity. We conducted a multicenter retrospective cohort study in term and preterm neonates with confirmed lower respiratory tract RSV infection, admitted to neonatal intensive care units (NICU) from 2000 to 2010. To determine which factors independently predicted the outcomes, multivariate logistic regression analysis was performed. A total of 259 term and preterm neonates were enrolled. Patients with a consolidation pattern on the chest radiograph at admission (n = 101) had greater need for invasive mechanical ventilation (OR: 2.5; P = .015), respiratory support (OR: 2.3; P = .005), supplemental oxygen (OR: 3.0; P = .008), and prolonged stay in the NICU (>7 days) (OR: 1.8; P = .025). Newborns with a consolidation pattern on admission chest radiograph had a more severe disease course, with greater risk of invasive mechanical ventilation, respiratory support, supplemental oxygen, and prolonged hospitalization.

Prospective validation of a novel strategy for assessing risk of significant hyperbilirubinemia.

OBJECTIVE: Our aim was to validate a strategy for assessing the risk of significant hyperbilirubinemia in newborns with gestational ages of ≥35 weeks by combining predischarge bilirubin percentile data with gestational age data, for a European, predominantly white population. METHODS: We conducted a prospective cohort study with 463 newborns with gestational ages of ≥35 weeks who were admitted to the well-infant nursery. Total bilirubin levels were measured daily until discharge and once after discharge, between the third and eighth days of life, by using a Bilicheck device (Respironics, Murrysville, PA). The values obtained (<52 hours) were plotted on an hour-specific bilirubin nomogram to determine the infant's bilirubin percentile, expressed as a risk zone. Patients were assigned to 1 of 3 risk groups (very low, low, or high) on the basis of a combination of risk zone and gestational age data and were monitored prospectively for the development of significant hyperbilirubinemia. The 95% confidence interval (CI) for the prevalence of significant hyperbilirubinemia was estimated with the binomial distribution method. RESULTS: Forty-four infants (11%) developed significant neonatal hyperbilirubinemia. The risks of developing significant hyperbilirubinemia were 1.3% (95% CI: 0.2%-3.7%) for the very low risk group (n = 230 [58.1%]), 3.4% (95% CI: 0.7%-9.8%) for the low risk group (n = 86 [21.7%]), and 47.50% (95% CI: 36.2%-59.0%) for the high risk group (n = 80 [20.20%]). CONCLUSIONS: The proposed strategy, based on predischarge bilirubin level and gestational age data, was a valid method for significant hyperbilirubinemia risk assessment in our population.

Demência pré-senil precedida por depressão / Pré-senile insanity preceded by depression

Com o aumento da expectativa de vida, visto hoje em todo o mundo, um maior número de pessoas entra na faixa senil, em que a manifestação de doenças demenciais é mais comum. Entre essas, a doença de Alzheimer (DA) é a causa mais freqüente de demência. Relata-se caso de um paciente com Doença de Alzheimer na forma precoce (<65 anos), que apresentou alterações de memória e progressivo declínio funcional cognitivo e sintomas comportamentais (insônia e agitação psicomotora), quadro este precedido por depressão. O diagnóstico diferencial dessa condição se baseou na busca de perfil clínico característico por anamnese adequada, exame neurológico, além da investigação complementar pertinente, que consiste em exames laboratoriais e de neuroimagem. O paciente foi avaliado com o teste Mini-mental e segundo os critérios da Organização Mundial da Saúde (OMS) e da Associação Psiquiátrica Americana (APA). Os inibidores da colinesterase no tratamento da doença de Alzheimer representam uma abordagem terapêutica promissora.

With the increase of the life expectancy that is seen today in the world, a larger number of persons reaches an senil's age when the manifestation of dementia's disease illnesses is more common. Among these, the Alzheimer's disease (AD) is the most frequent cause of dementia. We report a case of a patient with a Alzheimer's disease, in the early-onset (<65 years), who presented memory problems and progressive functional, cognitive and behavioral (insomnia, psychomotor agitation). This case preceded by depression. The differential diagnosis of this condition is based on a specific clinical profile defined through an adequate medical history, neurological examination, related laboratory tests and neuroimaging studies. The patient was the evaluated with a Mini-mental State, the criterias of World Health Organization (WHO) and American Psychiatric Association (APA). Cholinesterase inhibitors for treating in Alzheimer's disease represent a promising therapeutical approach.